hb``` ce`a`Y5 bR;)/}ksN}J^dcZ9@ @Hw400P`a Pl fKU0 e`c cpIqc1$frf3Hf6S\k{3*0ue`dzAyF ~ H00#9 L Healthcare Effectiveness Data and Information Set (HEDIS), Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Anthem HealthKeepers Plus Provider Manual, Long-term Services and Supports Authorization Guide. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. Inpatient services and nonparticipating providers always require prior authorization. Pharmacy Forms. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). Visit our PharmacyInformation page for formulary information and pharmacy prior authorization forms. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. Medical Injectable Drugs: 833-581-1861. Providers should continue to verify member eligibility and benefits prior to rendering services. You'll also find news and updates for all lines of business. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. Health Equity and Social Determinants of Health (SDoH), Over the Counter Equivalent Exclusion Program, Prior Authorization and Step Therapy Programs, Consolidated Appropriations Act & Transparency in Coverage, Medical Policy/Pre-certification: Out-of-area Members, 2021 Commercial Prior Authorization Requirements Summary, 2021 Commercial Outpatient Medical Surgical Prior Authorization Code List, 2021 Commercial Specialty Pharmacy Prior Authorization Drug List, 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List, New Prior Authorization Requirements for Some Custom Account Members Will Take Effect Jan. 1, 2021, 2021 Medicaid Prior Authorization Requirements Summary, 2021 Medicaid Prior Authorization Code List, 2021 MA PPO Prior Authorization Requirements Summary, 2021 MA PPO Prior Authorization Code List, BCBSIL Provider Network Consultant (PNC) team, Update: Utilization Management Change for Advocate Aurora Health Members, Effective Jan. 1, 2021 This News and Updates was posted Dec.15, 2020, and updated Dec. 31, 2020 to reflect a corrected phone number. In addition, some sites may require you to agree to their terms of use and privacy policy. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. The Anthem Alliance EPO 2022 prior authorization list has been updated effective January 1, 2022. Prior Authorization for Some Commercial Members Will Transition from eviCore to AIM, Effective Jan. 1, 2021 This notice was posted Oct. 1, 2020, to alert you of a utilization management vendor change. Electronic authorizations. PPO outpatient services do not require Pre-Service Review. Medicare Coverage with Anthem Medicare Information Medicare Coverage and Enrollment Turning 65 Medicare Advantage Plans: Part C Medicare Part D Plans Medicare Supplement Plans (Medigap) Dental and Vision Coverage CareCare What to Know Getting Better Care Preventive Health Find Care Medicare Caregiver Resources SupportSupport Login Registration A follow-up article with additional information on transition of member care was posted Dec. 4, 2020. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the members ID card. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. Enhanced Care Management (ECM) under CalAIM is a care management benefit that is community-based and provides a whole person approach to care that addresses the clinical and nonclinical needs of members with the most complex medical and social needs. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. Access eligibility and benefits information on the Availity Web Portal or Use the Prior Authorization Lookup Tool within Availity or Contact the Customer Care Center: Outside Los Angeles County: 1-800-407-4627 Inside Los Angeles County: 1-888-285-7801 Customer Care Center hours are Monday to Friday 7 a.m. to 7 p.m. To request or check the status of a prior authorization request or decision for a particular plan member, access our Interactive Care Reviewer (ICR) tool via Availity. The latest edition and archives of our quarterly quality newsletter. Bundling Rationale (Claims filed before Aug. 25, 2017). These documents contain information about upcoming code edits. In Ohio: Community Insurance Company. 844-912-0938 Email: OhioMedicaidProvider@anthem.com Prior authorization resources and contact information Services Requiring Prior Authorization Inpatient prior authorization fax numbers Physical health: 877-643-0671 Behavioral health: 866-577-2184 Medicaid prior authorization: 800-964-3627 Outpatient prior authorization fax numbers Community Supports under CalAIM are voluntary wrap-around services or settings available to members as a substitute for utilization of other services that focus on medical and/or needs that arise from social determinants of health. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Select Auth/Referral Inquiry or Authorizations. Future updates regarding COVID-19 will appear in the monthly Provider News publication. Details about new programs and changes to our procedures and guidelines. Get the latest news to help improve your life and keep you healthy. Forms and information about behavioral health services for your patients. Prior Authorization Requirements. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. Medicare with Medicaid (BlueCare Plus SM ) Medicaid (BlueCare) TennCare. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. Commercial Prior Authorization Summary and Code Lists ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. %%EOF Forms and information about pharmacy services and prescriptions for your patients. This approval process is called prior authorization. You'll also find news and updates for all lines of business. Start by choosing your patient's network listed below. Use of the Anthem websites constitutes your agreement with our Terms of Use. This includes our Medicaid Blue Cross Community Health PlansSM (BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM and Blue Cross Medicare Advantage (PPO)SM(MA PPO) members. Additionally, providers can use this tool to make inquiries on previously submitted requests, regardless of how they were sent (phone, fax, ICR or another online tool). The latest edition and archives of our monthly provider newsletter. Contact 866-773-2884 for authorization regarding treatment. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Plans for federal employees, retirees, retired uniformed service members, and active duty family members. Please note: This change is not applicable to the members enrolled in the Mercy Co-worker Plan as they have a customized prior authorization list. Please refer to the criteria listed below for genetic testing. We've provided the following resources to help you understand Anthem's prior authorization process and obtain authorization for your patients when it's required. HealthKeepers, Inc. recommends submitting prior authorization requests for Anthem HealthKeepers Plus members via Interactive Care Reviewer (ICR), a secure Utilization Management tool available in Availity. On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Anthem Blue Cross and Blue Shield. Select Patient Registration from the top navigation. In 2020, Part B step therapy may apply to some categories . In the event of an emergency, members may access emergency services 24/7. 2022 Standard Pre-certification list . Please check your schedule of benefits for coverage information. endstream endobj startxref From cleanings to crowns, BCBS FEP Dental coverage options are available for federal employees, retirees, and eligible retired uniformed service members. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. The BH prior authorization policy is outlined in the BH Provider Manual and can be accessed by following the instructions below. For costs and complete details of the coverage, please contact your agent or the health plan. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. Medicare Advantage. Forms and information to help you request prior authorization or file an appeal. Its critical to check member eligibility and benefits through the Availity Provider Portal or your preferred vendor portal prior to every scheduled appointment. Decide on what kind of signature to create. February 2023 Anthem Provider News - Virginia, New ID cards for Anthem Blue Cross and Blue Shield members - Virginia, Telephonic-only care allowance extended through April 11, 2023 - Virginia, January 2023 Anthem Provider News - Virginia, December 2022 Anthem Provider News - Virginia, Medicare Advantage Providers | Anthem.com, March 2022 Anthem Provider News - Virginia, K1022 Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type. BlueCross BlueShield of Tennessee uses a clinical editing database. These documents contain information about your benefits, network and coverage. Provider Enrollment Forms. An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patient's prescription cost. Independent licensees of the Blue Cross Association. Our Interactive Care Reviewer (ICR) tool via Availity is the preferred method for submitting prior authorization requests, offering a streamlined and efficient experience for providers requesting inpatient and outpatient medical or behavioral health services for our members. For more information, please refer to the Medical Policy Reference Manual. You can also check status of an existing request and auto-authorize more than 40 common procedures. Anthem offers great healthcare options for federal employees and their families. Prior Authorization Contact Information Providers and staff can also contact Anthem for help with prior authorization via the following methods: Utilization Management (UM) for Medi-Cal Managed Care (Medi-Cal) Phone: 1-888-831-2246 Hours: Monday to Friday, 8 a.m. to 5 p.m. Fax: 1-800-754-4708 Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services (CMS) guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Please refer to the criteria listed below for genetic testing. Anthem Blue Cross (Anthem) is available by fax or Interactive Care Reviewer (ICR) 24/7 to accept prior authorization requests. The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply. 711. To get started, select the state you live in. Commercial. Large Group CareFirst Commercial Pre-Service Review and Prior Authorization. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity. This step will help you determine if prior authorization may be required for a specific member and service. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. ) refer to your, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity or. Musculoskeletal (eviCore): 800-540-2406. With three rich options to choose from, weve got you covered. Long-Term Care (LTC) Forms. CareFirst does not guarantee that this list is complete or current. Information about benefits for your patients covered by the BlueCard program. Do not sell or share my personal information. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. State & Federal / Medicare. External link You are leaving this website/app (site). To view this file, you may need to install a PDF reader program. This approval process is called prior authorization. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. Serving Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri (excluding 30 counties in the Kansas City area), Nevada, New Hampshire, Ohio, Virginia (excluding the Northern Virginia suburbs of Washington, D.C.), and Wisconsin. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. 0 Availity Portal for behavioral health authorizations, or contactProviderServices for assistance. National Accounts, Posts about using health Insurance and managing your health, Collections of learning resources and links to services, For Sydney Health users connect with others and find care programs. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Look up common health coverage and medical terms. Access the BH Provider Manuals, Rates and Resources webpage here. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Availity, LLC is an independent company providing administrative support services on behalf of HealthKeepers, Inc. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). 451 0 obj <> endobj Serving Maryland, the District of Columbia and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield Medicare Advantage is the shared business name of CareFirst Advantage, Inc. and CareFirst Advantage DSNP, Inc. CareFirst BlueCross BlueShield Community Health Plan Maryland is the business name of CareFirst Community Partners, Inc. CareFirst BlueCross BlueShield Community Health Plan District of Columbia is the business name of Trusted Health Plan (District of Columbia), Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. The form contains important information regarding the patient's medical history and requested medication which Anthem will use to determine whether or not the prescription is included in the patient's health care plan. Do not sell or share my personal information. We encourage providers to use Effective 01/01/2023 (includes changes effective 04/01/2023) . Learn about the NAIC rules regarding coordination of benefits. Drug list/Formulary inclusion does not infer a drug is a covered benefit. Forms and information about behavioral health services for your patients. Medicaid Behavioral/Physical Health Coordination. Referencing the . U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. Prior authorization requirement changes effective June 1, 2022 Mar 1, 2022 State & Federal / Medicare On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Anthem Blue Cross and Blue Shield. * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. If you have any questions, call the number on the members ID card. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. CareFirst reserves the right to change this list at any time without notice. ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. cost of services to the member if denied by Anthem for lack of medical necessity: (1) Procedures, equipment, and/or specialty infusio n drugs which have medically necessary criteria determined by Corporate Medical Policy or Adopted Clinical Guidelines. Prior authorization to confirm medical necessity is required for certain services and benefit plans as part of our commitment to help ensure all Blue Cross and Blue Shield of Illinois (BCBSIL) members get the right care, at the right time, in the right setting. Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Providers should continue to verify member eligibility and benefits prior to rendering services. rationale behind certain code pairs in the database. Any drugs, services, treatment, or supplies that the CareFirst medical staff determines, with appropriate consultation, to be experimental, investigational or unproven are not covered services. In Indiana: Anthem Insurance Companies, Inc. In Ohio: Community Insurance Company. * Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. Please check your schedule of benefits for coverage information. Third-Party Liability (TPL) Forms. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). Follow the step-by-step instructions below to design your anthem forms: Select the document you want to sign and click Upload. Drug list/Formulary inclusion does not infer a drug is a covered benefit. Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. 477 0 obj <>/Filter/FlateDecode/ID[<530E5E682DBDAA468541E11BFAD96BAD>]/Index[451 44]/Info 450 0 R/Length 122/Prev 255106/Root 452 0 R/Size 495/Type/XRef/W[1 3 1]>>stream Medicare Advantage Providers Anthem offers a variety of Medicare plans to support member needs. PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. Prior authorization requirements will be added for the following codes: Not all PA requirements are listed here. Providers and staff can also contact Anthem for help with prior authorization via the following methods: Pharmacy Prior Authorization Center for Medi-Cal: *For Medicare-Medicaid Plan pharmacy requests, please contact Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) Customer Care at 855-817-5786. Summaries and code lists are posted as a reference to help you determine when prior authorization may be required for non-HMO government programs members. One option is Adobe Reader which has a built-in reader. We look forward to working with you to provide quality services to our members. In Kentucky: Anthem Health Plans of Kentucky, Inc. Anthem does not require prior authorization for treatment of emergency medical conditions. Part B Step Therapy (204 KB) Drug step therapy is a type of prior authorization that requires one drug (or drugs) to be tried for a medical condition prior to utilizing other drugs; the steps typically require lower cost drugs or drugs with better clinical outcomes to be tried first. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. This list may vary based on account contracts and should be verified by contacting 1-866-773-2884. endstream endobj 452 0 obj <. Its important to remember that benefit plans differ in their benefits, and details such as prior authorization requirements are subject to change. Benefits will be determined once a claim is received and will be based upon, among other things, the members eligibility and the terms of the members certificate of coverage applicable on the date services were rendered. FEP Medications requiring online prior authorization, Intravenous Immune Globulin (IVIG) Therapy, Stereotactic Radiosurgery Using Gamma Rays, Surprise Billing - Out-Of-Network Provider Notice, Ambulance -elective air transport only (10.0.005), Behavioral Health and Substance Use Disorder (Milliman Care Guidelines), Repetitive Transcranial Magnetic Stimulation (TMS), Inpatient Behavioral Health and Substance Use Disorder, Home health care (Criteria defined in the employer group benefit contract), Home Infusion Therapy (Criteria defined in the employer group benefit contract), Hospice (Criteria defined in the employer group benefit contract), Inpatient rehabilitation (Apollo Managed Care Physical Therapy, Occupational Therapy and Rehabilitation Care), Maternity Services- inpatient only, for stay greater than 48/96 hours (Criteria defined in the employer group benefit contract), Out-of-network services (Benefits available according to the member contract), Private Duty Nursing (Criteria defined in the employer group benefit contract), Skilled nursing facility admissions (Apollo Managed Care Physical Therapy, Occupational Therapy and Rehabilitation Care). In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. Phone - Call the AIM Contact Center at 866-455-8415, Monday through Friday, 6 a.m. to 6 p.m., CT; and 9 a.m. to noon, CT on weekends and holidays. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. For your convenience, we've put these commonly used documents together in one place. Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. Providers should call the prior authorization number on the back of the member ID card. These manuals are your source for important information about our policies and procedures. Note: Blue High Performance NetworkSM (BlueHPNSM) members have limited benefits at the University of Maryland Medical System Downtown Campus. 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